Common Working File Incorrectly Rejecting for Edit 538H

National Government Services is informing Part A and Part B providers of an error in CWF in the Eligibility Database, incorrectly identifying some beneficiaries as incarcerated and rejecting new claims for Edit 538H. This may also generate informational unsolicited responses (IURs) for claims that processed after the incarceration date.

Part A and Part B providers in Jurisdiction K and Jurisdiction 6

Portable X-Ray Pricing Update

Portable X-ray pricing fees for CY 2024 will have new fees in production by 9/6/2024.

Part B providers in Jurisdiction 6 and Jurisdiction K

Temporary Holding for Some Part B Claims

An issue has been identified resulting in the need to hold a segment of claims until the appropriate system fix can be installed.

Jurisdiction 6 and Jurisdiction K Part B Providers

Botox Chemodenervation Administration Codes

The above-described administration codes are billed on the Part B claim without the corresponding drug J0585, J0586, J0587 or J0588 and the claim rejects with messages CO16 N56 MA130. The article A52848 indicates the drug should be billed on the same day/same claim; however when the drugs are administered in the hospital outpatient setting, the hospital must bill for the drugs on correlative Part A claim. When the administration services are billed in the outpatient/inpatient setting the Part B claim with the services should be allowed.

Jurisdiction 6 and Jurisdiction K Part B Providers

Home Health Core-Based Statistical Area Payment issue (Code 50007)

CBSA Code 50007 was loaded into the CY 2021 wage index table of the home health (HH) Pricer with an incorrect effective date. This error is causing incorrect payment on claims with CBSA 50007 in the Value Code 61 amount field by using the wrong wage index in payment calculation. National Government Services (NGS) has been instructed by the Centers for Medicare & Medicaid Services (CMS) to suspend claims with CBSA Code 50007 and to change it to CBSA Code 28020 which will utilize the correct wage index, allowing for accurate payment for these claims.

Part A home health providers in Jurisdiction K and Jurisdiction 6

Hospice Informational Unsolicited Response Adjustments - Type of Bill 8XG

Due to original informational unsolicited responses (IURs) processing not occurring between the timeframe of 8/1/2017 and 4/1/2021, a significant volume of hospice IUR adjustments have been initiated by the common working file (CWF) to determine if a payment adjustment was necessary. Adjustments may or may not have resulted in payment changes.

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Part A hospice providers in Jurisdiction K and Jurisdiction 6

Incorrect Billing for Part A Outpatient Observation Services

The CMS billing instructions for G0378 indicate a single line of coding with a NOS of at least eight, with all UOS on a single line and the DOS being the date of the original observation order. Claim editing changes implemented in July, 2021 are correctly rejecting observation services billed on separate lines. If multiple lines of G0378 are reported on a claim, the claim will now RTP with reason code W7051. All units of service must be reported on a single line to resolve the edit. If you have submitted an appeal request on a claim with inappropriate billing of multiple lines of G0378, any claim adjustment due to the appeal decision will result in the lines being combined. This may cause payment to then be made under a comprehensive APC on a 13X bill type, if units of G0378 are equal to or greater than 8 and you also billed on the same line item date of service or the day before the date reported for observation:

• A Type A or B emergency department visit (CPT codes 99281 through 99285 or HCPCS codes G0380 through G0384)
• A clinic visit (HCPCS code G0463); or
• Critical care (CPT code 99291); or
• Direct referral for observation care reported (HCPCS code G0379) (must be reported on the same date of service as the date reported for observation services.)

Appeals for these claim denials have resulted in significantly lower payments based on assignment of the comprehensive APC.

Jurisdiction 6 and Jurisdiction K Part A Providers

Part B Remittance Statements Missing Financial Control Numbers

Due to an issue associated with the 10/1/2021 release, Part B remittances classified as withholding (WO) are being generated without FCN information. Without the necessary control number, providers cannot cross-reference the reason for financial offset. 

Jurisdiction 6 and Jurisdiction K Part B Providers

Part A 11X Claims Returned to Provider

11X claims with DOS prior to 10/1/2021 with ICD-10 diagnosis code Z515 and POA indicator of Y have RTP with edit message 34931.

Jurisdiction 6 and Jurisdiction K Part A Providers

Processing Issue Botulinum Toxin Claims Returned to Provider with 5PRIA

Part A claims that have been submitted with Botulinum J codes (J0585, J0586, J0587, J0588) have incorrectly RTP with reason code 5PRIA.

Jurisdiction 6 and Jurisdiction K Part A Providers

Part B Issue for Coinsurance Payments on Drug Code Claims

Due to an issue with a recent system update, 20% coinsurance for drug codes has been incorrectly calculated during the period of 10/27/2021-11/1/2021.

Jurisdiction 6 and Jurisdiction K Part B Providers

U537F Assigning in Error On Some Notices of Admission

National Government Services has identified an issue where U537F is assigning incorrectly on some NOAs, due to the CWF not correctly recognizing discharges (patient status other than 30 on the last HH period). There is no workaround.

Please note: This edit will also assign correctly on duplicate NOAs for the same admission period. Please ensure an NOA is not already in the system pending processing or finalized prior to submitting a new NOA for a beneficiary. Home health agencies should not be submitting multiple NOAs for same admission.

The U537F edit will also assign correctly on NOAs if the provider CCN does not match the CCN on the prior HH episode posted at CWF. In this situation, the NOA should be billed with a condition code 47.

Jurisdiction 6 and Jurisdiction K Home Health providers

Part A Anesthesia Claim Returning to Providers in Error​​​​​​​

CMS has instructed all MACs to hold all Part A 13X and 85X TOBs for anesthesia services with DOS on or after 1/1/2022 until CMS fully implements a replacement file for these claims.

Jurisdiction 6 and Jurisdiction K Part A Providers

>Part A FISS Cancel Adjustment Issue

FISS Maintainer will be creating a file to identify the cancel claim records that posted to the CWF as original claims (those with a CD value of “3” instead of “4”) and will be providing those files to CWF. The CWF Maintainer will run those files through the HIMR to cancel the incorrectly posted records.

Jurisdiction 6 and Jurisdiction K Part A Providers

Anesthesia CPT 00537 Being Underpaid for 2022

The 2022 Anesthesia Base Unit for 00537 was not updated for dates of service starting 1/1/2022 which has caused services being underpaid.

Jurisdiction 6 and Jurisdiction K Part B Providers

Anesthesia Conversion Factor Pricing Incorrect for 2022

The incorrect conversion file was loaded to production for dates of service starting 1/1/2022 which caused incorrect payments.

Jurisdiction 6 and Jurisdiction K Part B Providers

Home Health 32G Adjustment Issue for Separation Periods of < 60 Days

A segment of home health claims with 32G type of bills are incorrectly being re-coded to earlier periods during processing, instead of the correct later periods. This error is occurring when the separation between the two periods is 60 days or less. Based on the PDGM, the first digit of the HIPPS code identifies the period as either early (digits 1 or 2) or later (digits 3 or 4). When the periods are adjacent, meaning they are separated by no more than a 60-day period, the HIPPS code should begin with 3 or 4.

Part A Home Health providers in Jurisdiction 6 and Jurisdiction K

COVID-19 Vaccine Administration Returning to Providers - Reason Code 32287

Claims for COVID-19 vaccine administration performed on the same DOS as another vaccine administration (e.g., PPV, flu or tetanus) are incorrectly being returned to providers with RC 32287.

Jurisdiction 6 and Jurisdiction K Part A Providers

Part A Invalid MBI Cross-Reference Issue

National Government Services is informing Part A providers of a claim processing issue causing invalid MBI cross-referencing. This is resulting in multiple, inactivated HICN being associated with the impacted claims.

Part A and home health and hospice providers in Jurisdiction K and Jurisdiction 6

Optical Character Recognition Misreading Referring Provider Names

OCR software is misreading the referring/ ordering provider name (item 17) on some Part B claims.

Jurisdiction K and Jurisdiction 6 Part B providers

340B-Acquired Drugs Payment Differential Cancellation

Previously applied differential payment rates for 340B-acquired drugs are no longer valid as of 9/28/2022, as per a ruling by the United States District Court for the District of Columbia. As a result, the CMS will revert to paying the default rate (generally ASP plus 6%) under Medicare statute for 340B-acquired drugs. CMS is uploading revised OPPS drug files that will apply the default rate (generally ASP plus 6%) to 340B-acquired drugs for the rest of the year. CMS also will reprocess claims our contractors paid on or after 9/28/2022 , using the default rate (generally ASP plus 6%).

Part A providers in Jurisdiction K and Jurisdiction 6

Home Health Claims Incorrectly Receiving Reason Code U538E

HH final and adjusted claims with 2022 dates of service are receiving U538E incorrectly, when there is an older period on file. This prevents providers from being able to adjust these claims and update patient status from “06” to any other patient status.

Part A home health providers in Jurisdiction K and Jurisdiction 6

Anesthesia Services Are Being Denied When Billed with Radiofrequency Ablation Services

National Government Services is currently denying anesthesia when reported with radiofrequency ablation (RFA) services. Radiofrequency ablation, which requires the patient to remain motionless for prolonged periods of time or remain in a painful position, may require moderate sedation or an anesthesia care team. Based on this, NGS will be adjusting all anesthesia services that have been denied when billed with RFA services.

Part A and Part B providers in Jurisdiction K and Jurisdiction 6

Home Health Claims Returned to Providers with Reason Code 31755​​​​​​​

CMS reactivated RC 31755 effective 1/3/2023 and some HH claims are being RTP due to billing errors. These claims need to be corrected with the information provided in the Provider Action section of this article. Medicare is still receiving claims for January 2022 that used an artificial admission date, causing the claims to RTP with RC 31755. These claims are being researched to determine what action is required.

Jurisdiction 6 and Jurisdiction K Part A Home Health Providers

Part A Claims RTP RC 38361

Claims are continuing to incorrectly RTP even when the prior claims are not No Pay Claims.

Jurisdiction 6 and Jurisdiction K Part A Providers

Rural Health Claims Impacted by FS2540

This utility will adjust Rural Health claims - 71X TOB

• Reimbursed incorrectly with the implementation of FS2540 in the A20232CP release
• Installed to production on 5/15/23

Note: changes for FS2540 were backed out with FS2540R1 on 6/13/23.

This utility is to correct claims paid between 5/15/23 and 6/13/23.

Report RPTCLHM1 will identify claims that have been adjusted. These will be set to SB0100 and process as 71J bill types.

Jurisdiction 6 and Jurisdiction K Part A Rural Health Centers

Hospice Claims Edit Issue RC W7048

National Government Services has noted an increase in hospice claims editing incorrectly for RC W7048 following the July 2023 system release. This is occurring for revenue codes 0250 (non-injectable prescription drugs), 0290 and/or 0294 (infusion DME and drugs), which do not require HCPCS codes.

Hospice providers in Jurisdiction K and Jurisdiction 6

RC 55A00 or 55A01 Denials for Denosumab

National Government Services is aware of an issue that is causing claims to deny in error with reason code 55A00 or 55A01. The claims involved are for Denosumab (J0897) - Billing and Coding article – A52399 and are firing on edit 5XX84.

Jurisdiction 6 and Jurisdiction K Part A Providers

RC 34963 – Provider Enrollment Issue

An issue in the PECOS is causing some Part A claims to RTP in error with RC 34963.

Jurisdiction 6 and Jurisdiction K Part A Providers

ESRD Claims Are Paying Incorrectly

National Government Services has been made aware of ESRD claims with HCPCS code 90999 processing at rates that are cents instead of hundreds of dollars. This is causing the claims to pay incorrectly. This issue appears to have started mid-July, 2023.

Part A ESRD Providers in Jurisdiction K and Jurisdiction 6

Part A Ambulance Claims Not Retaining Fractional Units

Fractional Units are not being retained on ambulance mileage HCPCS entered via DDE. This results in reason code 32226 (Units required but not present).  

Part A providers submitting DDE ambulance claims in Jurisdiction 6 and Jurisdiction K

Reimbursing Place of Service 10 at the Nonfacility Rate for Medicare Telehealth Services

In CY 2024, CMS issued a change to processing for telehealth services billed with POS 10. As of 1/1/2024, these claims are to be paid at the nonfacility PFS rate. A system processing issue resulted in incorrect payments at the facility rate and this issue has now been corrected. As per CMS instructions issued 2/21/2024, NGS will initiate a mass adjustment of all impacted claims with dates of service 1/1/2024 and after.

Part B providers in Jurisdiction 6 and Jurisdiction K

Home Health Claims Returning to Provider RC 19963

HH claims are returning to provider in error with RC 19963. This impacts HH claims with NOA/processed dates in January 2022. NOAs are being purged after 24 months. Please keep in mind there are claims that edit correctly for this reason code. RC 19963 assigns correctly if:

• There is no NOA on file for that admission,
• The NOA was submitted but was rejected/RTP
• The NOA was cancelled by the home health agency (HHA) and never resubmitted,
• The NOA and claim admission dates do not match, or
• The admission was closed by another claim with an earlier service date.

HH providers billing HH claims with NOA admission/processed dates in January 2022.

Hospice Claims Rejected with Reason Code 17729

Claim rejections for TOB 081X and 082X with RC 17729 have occurred due to a file error. These claims did comply with CMS-required entry of the correct certifying physician in the “Attending” field, which did match the PECOS Enrolled Physicians File and did fall within a physician’s effective/termination dates. This error occurred on claims with “From” dates on or after 6/3/2024.

Part A hospice providers in Jurisdiction K and Jurisdiction 6